Laserfiche WebLink
SAN JOAQUI,N LOCAL WEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209) 466-6781 -3 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. _ 1 - r <br /> THIS PERMIT EXPIRES 1-- YEAR- FROM DATE ISSUED Date Issued Z <br /> (Complete In Triplicate) <br /> Application is �hereby= - <br /> madeto 'the- San,Joaquin Local. Health District for a permit td-construct <br /> and/or install the work herein described. This application .is made in compliance with San Joaquin , <br /> County Ordinance No.>,1862 and-,the Rules and Regulations of the San Joaquin Local Health District. <br /> 1-001 <br /> JOB ADDRESS/LOCATION / �, ` Gi 1V• %�c,4G �! /Z U CENSUS TRACT <br /> Owner.':s: Name'l IT 'a LA _ 7' !, ' z, , ,, -. - Phone 0/ i <br /> Address 4.11 w ra ff Vic. City C 7101 CA 4. <br /> Contractor's Name License # i 45o_�r Phone Ytrs-/p,+' . <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/_/ RECONDITION /-7 DESTRUCTION /7 w <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> _ SEWAGE_DISPOSAL FIELD _ CESSPOOL/SEEPAGE .PIT OTHER <br /> INTENDED USE TYPE-OF'WELL CONSTRUCTIONSPECIFICATIONS <br /> Industrial. y( Cable Tool Dia. of Well Excavation ya- <br /> 7. Domestic/private Drilled Dia. of Well Casing /011 G` <br /> Domestic/public - _ Driven Gauge of Casing <br /> - Irrigation Gravel Pack Depth of Grout Seal r4 " <br /> Other Rotary Type of Grout <br /> Other Other Information' t` <br /> PUMP INSTALLATION: Contractorjai j� <br /> Type of Pump H.P. /D <br /> PUMP REPLACEMENT: /' / State Work Done <br /> PUMP REPAIR:. / / State-Work Done. <br /> .2ESTRU_CTI.O_N OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY�- DATE 'Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> 1 INSPECTION BY DATE 2/.b '��- INSPECTION BY DATE �'7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> EH 1426 4/72 1M <br />